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    Open Fractures – Initial Approach and Management

    Orthopedic, Trauma

    Last Updated Aug 04, 2023
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    By Tyler Martin, Damian Feldman-Kiss, Josh Williams

    First 5 Minutes

    • In general, open fractures are addressed after initial resuscitation priorities are dealt with.
    • Open fractures are a time-dependent orthopedic emergency due to the risk of osteomyelitis.
    • Open fractures require urgent IV antibiotics; regimen depends on grade of fracture and contamination profile.
    • Remove gross debris (e.g., clothing, wood, leaves); control hemorrhage in the field with a sterile pressure dressing.
    • Irrigate the wound with sterile isotonic saline using low pressure, cover with saline soaked gauze after arrival in the ED.
    • Administer tetanus prophylaxis; large crush wounds may require tetanus immune globulin.


    • Open fractures have a direct communication to the external environment.
    • Extent of damage to the deeper structures may not be reflected by the size and nature of the external wound.
    • Infection occurs at a higher incidence in open fractures compared to closed.
    • The number and severity of comorbidities increases the risk of infection and compromises wound healing. Three or more of the following risk factors increase the incidence of infection up to 31% (Howe, 2021):
      • Age >/= 80 years old
      • Nicotine use
      • Diabetes
      • Active malignancy
      • Pulmonary insufficiency
      • Immunocompromised state
    • Complications include:
      • Osteomyelitis
      • Malunion
      • Nonunion

    Diagnostic Process

    • Open fracture is a clinical diagnosis involving a detailed physical exam supplemented with radiography.
    • History
      • Focus on mechanism, timing, and location of injury.
      • Screen for farming-related injury or any fecal contamination.
    • Physical exam
      • Assess neurovascular status of all limbs involved for potential nerve or vascular injury.
    • Imaging
      • Obtain radiographs; consider including joint above and joint below.
      • The Gustilo-Anderson is commonly used in the description of open fractures and to guide management:
        • Class I
          • Low energy
          • Wound <1 cm long
          • Minimal contamination, comminution, and soft tissue damage
          • Infection rate: 0-2%
        • Class II
          • Moderate energy
          • Wound 1-10 cm long
          • Moderate soft-tissue damage
          • Minimal periosteal stripping
          • No flaps, crushing, or gross contamination
          • Infection rate: 2-5%
        • Class IIIA
          • High energy
          • Wound usually >10 cm long
          • Extensive soft-tissue damage, contamination, comminution, and periosteal stripping with adequate soft tissue coverage
          • Infection rate: 5-10%
        • Class IIIB
          • High energy
          • Wound usually >10 cm long
          • Extensive soft-tissue damage, contamination, comminution, and periosteal stripping without adequate soft tissue coverage
          • Infection rate: 10-50%
        • Class IIIC
          • Open fracture complicated by vascular injury requiring repair for limb viability
          • Infection rate: 25-50%

    Recommended Treatment

    • Primary survey with early hemorrhage control by applying a sterile pressure dressing; resuscitate as needed.
    • Appropriate analgesia
      • Opioids and/or ketamine.
    • Gentle removal of any gross debris.
    • Irrigation and coverage
      • Irrigate wound with copious sterile saline at low pressures, then cover with saline soaked sponges (better outcomes when compared to higher pressure irrigation or a soap solution.)
    • Reduce fracture and immobilize.
    • Start IV antibiotic prophylaxis immediately
      • Gustilo Grade I:
        • First-generation cephalosporin (cefazolin 2g IV q8h x 2 days) or clindamycin 900 mg IV q8h if allergic.
      • Gustilo Grade II/III:
        • First-generation cephalosporin (cefazolin 2g IV q8h x 2 days), AND
        • Gentamicin 5 mg/kg IV once daily x 3 days for gram-negative coverage
          • Beta-lactams with both gram-positive and gram-negative coverage (e.g., ceftriaxone, pip-tazo) may provide equal benefit to cefazolin/gentamicin regimen.
        • ADD high-dose ampicillin or penicillin for fecal contaminated and/or farm-related injuries (potential clostridium contamination.)
    • Determine the patient’s tetanus immunization status and administer prophylaxis +/- immune globulin as needed.
    • Consult orthopedics +/- vascular surgery if concern for vascular injury; NPO and prepare for OR.


    • Open tuft fracture of the fingers and toes:
      • Immediate consultation is not indicated – many can be managed by emergency physician/primary care provider.
      • Infections are rare; vigorous irrigation and debridement is adequate.
      • In grossly contaminated wounds and/or patients at high risk for infection, antibiotic prophylaxis with a first-generation cephalosporin is reasonable (e.g., cephalexin 500 mg PO QID x 3 to 5 days.)

    Criteria For Hospital Admission

    In general, patients should be admitted for IV antibiotics and urgent surgical management.


    Criteria For Transfer To Another Facility

    • If the open fracture is minor and isolated, with no concern for vascular injury, referral to a center with orthopedics is warranted.
    • If moderate to severe, there is a concern for associated vascular injury, and/or the fracture is in the context of polytrauma, patients should be transported to a trauma referral center.

    Quality Of Evidence?


    • Expert opinion. Presumed benefit – not ethical to do RCT.
    • Timely administration of IV antibiotics minimizes the risk of infection and improves outcomes and is supported by high quality evidence. Irrigation of wounds with isotonic low-pressure saline is essential; an international, blinded RCT involving 2447 patients showed no improved outcomes when using either soap solution or high-pressure irrigation to clean open fractures.

    Related Information

    Reference List

    1. Diwan A, Eberlin KR, Smith RM. The principles and practice of open fracture care, 2018. Chinese Journal of Traumatology. 2018 Aug 1;21(04):187-92.

    2. Geiderman JM and Torbati S. General Principles of Orthopedic Injuries. In: Walls RM, Hockberger RS, Gausche-Hill M, Erickson TB, Wilcox SR, editors. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 10th ed. Philadelphia (US): Elsevier; 2023. p. 438-458.

    3. Howe AS. 2021. General principles of fracture management: acute and late complications. UpToDate. Retrieved June 8, 2023, from https://www.uptodate.com/contents/general-principles-of-fracture-management-early-and-late-complications?search=open%20fracture&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H66786337

    4. Okike K, Bhattacharyya T. Trends in the management of open fractures: a critical analysis. JBJS. 2006 Dec 1;88(12):2739-48.

    5. Sop JL, Sop A. Open Fracture Management. StatPearls. 2017 Aug 29. PMID: 28846249

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